In January, Philadelphia public health workers began offering free, weekly syphilis testing at drop-in centers where women who are homeless can get food, clothing and a hot shower.
The work is in response to a recent spike in local syphilis cases among women. APHA member Cherie Walker-Baban, program manager in the Philadelphia Department of Public Health’s STD Control Program, said health workers had been preparing for the possibility, as syphilis upticks often accompany addiction epidemics such as the current opioid crisis.
In fact, she said partnering with local drop-in centers is the same strategy health workers used in the 1990s to contain a syphilis uptick during the crack cocaine epidemic.
“It’s never-ending,” Walker-Baban said of STD prevention and control. “We may not see a disease for a while, but when it shows its head, we have to go full force at it so it doesn’t get out of control. And that’s regardless of what funding we have.”
Unfortunately, syphilis is just one of the sexually transmitted diseases making a comeback across the country. According to the Centers for Disease Control and Prevention, STD rates have experienced a “steep and sustained” increase in the past few years.
Between 2013 and 2017, U.S. cases of gonorrhea increased 67 percent. Cases of primary and secondary syphilis — a disease that had reached an all-time low in 2000 — increased 76 percent, with the bulk of cases among gay, bisexual and other men who have sex with men.
Syphilis more than doubled among women, with CDC researchers finding an association between heterosexual syphilis transmission and use of methamphetamine, injection drugs and heroin.
Cases of congenital syphilis — syphilis passed from woman to baby, which can result in miscarriage, infant death and lifelong health problems — are up from 326 cases in 2013 to more than 900 in 2017, CDC reported. Chlamydia is still the country’s most common STD, with 1.7 million diagnosed cases in 2017.
Despite the rising rates, federal funding for STD prevention has failed to keep up. In a December report from the National Academy of Public Administration, “The Impact of Sexually Transmitted Diseases on the United States: Still Hidden, Getting Worse, Can Be Controlled,” authors said that even though funding for CDC’s Division of STD Prevention has been level for the last few years at about $157 million, failing to adjust for inflation means the division’s purchasing power has gone down 40 percent since 2003.
According to Matthew Prior, MPH, director of communications at the National Coalition of STD Directors, an increase of at least $70 million is needed to jump-start a response to rising STDs and ready the public health workforce for STD challenges, such as emerging antibiotic-resistant gonorrhea.
He also noted that rising STD rates could threaten progress on HIV, which continues to decline in the U.S. thanks to preventive and medical advances such as pre-exposure prophylaxis. A study published this year found that 10 percent of all new HIV cases among men who have sex with men in the U.S. are attributable to gonorrhea and chlamydia infections.
“We’re very optimistic that the field will eventually get the resources it needs to address the problem,” Prior told The Nation’s Health. “Our concern is that by the time we receive it, it might be too late.”
In addition to funding problems, advocates and public health workers point to a number of likely contributors to the STD rise, including the shuttering of public health STD clinics, a lack of comprehensive sex education, not enough primary care providers equipped to address sexual health and persistent social stigmas around STDs. Health workers also caution that some of the rising statistics may reflect the success of better screening protocols and greater access to STD testing via the Affordable Care Act.
“There’s no one thing that’s going to change this,” Zandt Bryan, infectious disease field services coordinator at the Washington State Department of Health, told The Nation’s Health. “Any effort will do a better job with better resources, but we have a lot of work to do around building sexual health and education services into the contexts in which people live and in which they seek health care.”
In Washington state, Bryan said cases of syphilis, gonorrhea and chlamydia began to jump around 2011-2012, though the most recent preliminary data show that the rate of increase may be slowing down.
One of the agency’s responses has been prioritizing outreach to providers who come in contact with at-risk populations, such as reaching out to perinatal and obstetric providers on the importance of syphilis testing early in a woman’s pregnancy.
Bryan noted that a major challenge to STD prevention is many primary and family care providers do not routinely screen for STDs or are reluctant to talk about sexual health. On the flip side, people often prefer to get their sexual health care at STD clinics. A 2015 study in APHA’s American Journal of Public Health found that even among people with access to other types of health care settings, people still chose STD clinics for their convenience, low-cost and expert care.
That dynamic means despite the ACA’s expanded coverage of STD screening, the closure of STD clinics often leaves communities with a screening gap. CDC reported the closure of 21 local public health STD clinics in 2012.
“There has to be a shift in how our culture treats (STDs) — it needs to be seen as a standard part of health care,” Bryan said.
Across the country in Vermont, health officials have also recorded a rise in STD rates, which is forcing workers to be more targeted with their limited resources, said Daniel Daltry, MSW, program chief of the HIV, STD and Hepatitis C program at the Vermont Department of Health.
In the mid-2000s, Daltry said that he and colleagues used to interview every Vermont resident diagnosed with chlamydia as part of the agency’s disease control efforts. But that practice ended after the chlamydia caseload got too big to keep up with.
Daltry said that while the number of reported STD cases in Vermont has gone up, it is difficult to discern based on available data how much of the rise is due to better screening, versus new transmission.
Michael Kharfen, senior deputy director in the HIV/AIDS, Hepatitis, STD and TB Administration at the D.C. Department of Health, agreed that rising STD rates are likely due, in part, to better screening. For example, he said the agency’s STD clinic — which dropped “STD” from its name three years ago to help destigmatize sexual health and is now the D.C. Health and Wellness Center — has experienced a 100 percent increase each year for the last three years in the number of patients on PrEP.
And every person who begins a PrEP regimen is screened for STDs multiple times a year. Kharfen said updated surveillance at the agency, such as improved electronic lab reporting, is also providing a more complete picture of the city’s STD burden.
Overall, D.C.’s STD rates have mirrored increases at the national level, and Kharfen believes a contributor to new infections is a lower perception of risk among sexually active young people.
“We need more investment, so we can get better data,” he told The Nation’s Health. “At the same time, more people are being screened and treated, which means we’re being more successful in keeping people healthy.”
With insufficient resources and rising needs, the STD prevention field is ripe for innovation. The National Association of County and City Health Officials is leading one such effort. The CDC-funded Express STI Visits Initiative launched in February 2018 to build an evidence base for triage-based STD testing without a full clinical examination.
The exact details of express testing vary across the initiative’s 15 clinic sites — the majority run by health departments — but the general gist is that patients can walk in without an appointment, complete a quick screening tool, and if eligible for express testing, can self-collect their samples and have their blood taken without visiting with a clinician. A 2013 study on express STD testing in Australia found that the practice increased the number of patients seen by 11 percent, reduced costs per patient and reduced wait times.
“The goal is to create a really positive STD testing environment where we want someone to go and think that wasn’t so bad at all, and then bring their partners and friends,” said Samantha Ritter, MPH, who oversees the CDC initiative at NACCHO. “And express testing is really the closest we’ve come to being able to provide that experience.”
One of the 15 initiative sites is the Rhode Island STD Clinic at Miriam Hospital, the state’s only publicly funded STD clinic.
Philip Chan, MD, MS, the clinic’s medical director, opened the clinic with the support of Brown University after the state-run clinic across town shut down due to funding problems.
The clinic, which has been offering its own form of express testing since 2012, now tests about 4,000 people a year and is the sole safety net provider of STD services in the state. Like the rest of the country, Chan said the state has experienced a big STD increase.
But if more innovative screening techniques such as express STD testing prove sustainable, effective and replicable, Chan said it could greatly expand access and “change the paradigm” of how people get tested for STDs.
“We could eliminate STDs and HIV tomorrow if we could get everyone tested and treated,” Chan told The Nation’s Health. “Testing is the backbone of prevention.”